Re:Exposure in the real world

Client:

You make some wonderfully astute comments. I hope that I can add a few additional thoughts.

Regarding treatment compliance, this is a very interesting issue. I think there are two aspects of treatment compliance. This first is compliance with the therapeutic tasks undertaken in session, and the second is compliance with the therapeutic tasks prescribed as homework.

It is relatively easy to gain compliance in session, particularly in the kind of setting in which I work. We are recognized as a world-expert clinic that leads the field in research in the specific areas of PTSD and OCD. So, we have a lot of credibility from the outset. Related to this, we are specialists, kind of like a surgeon. We only provide certain treatments for certain conditions. We do not practice outside of our specific areas of competance. Most therapists don't have the luxery of being as specialized. From the the get go, we make it very clear to patients that we provide a specific service for specific problems, and that service is cognitive-behavior therapy which almost always invovles some kind of exposure therapy component. (Generalized anxiety disorder is one exception, where research shows that probably the best treatment is anxiety management training.)

Thus, once we are at the point of actually starting exposure with a patient, they have survived a rigorous assessment and education process. It is true that some peoople decline our services, based on not being comfortable with the idea of exposure. However, most of us have become pretty good spokes people for the treatment. Again, our status as "experts" helps us in this regard. In addition, when you present the therapy in user-friendly terms, it really makes sense to most patients. For example, if you pose a hypothetical situation such as "Let's say a little boy gets bitten by a stray dog and starts to fear all of the friendly dogs in the neighborhood, how would you help this child overcome his fear of dogs?" Most people intuitively know that the answer involves gradually comming into increasing contact with safe dogs and then learning to tell the difference between safe and unsafe dogs (e.g., tail wagging vs. tail between the legs).

On the other hand, it is always intersting to watch therapists as they are just learning to use exposure therpay. They are often less sure of themselves and about the efficacy of the technique. They often seem more timid in "prescribing" the therapy and possibly as a result may experience more resistance. However, as both the patient and the therapist wade thier way through the treatment, the "magic" of exposure therapy begins to work for both of them. Patients start to see that their anxiety in response to the memory does decrease, which is followed by noticible reductions in their target symptoms. The therapist also sess this, and their fear of "traumatizing" the patient also diminishes. We therapists are governed by the same laws of behavior as our patients.

In regard to homework compliance, there is little data on this point. Those of us who practice cognitive-behavior therapy tend to think homework is important. We think so for two reasons. First, we believe there is a kind of "dose-response" relationship, such that more treatment is better (to a point, anyway). Homework is an inexpensive way of getting more treatment. Second, we believe that we are teaching people skills that, by the end of therapy, they can own and take with them. So that if their have future difficulties, they will be better equipped to handle them without the need of professional assistance.

Now, once again, these are beliefs. What are the facts? In PTSD, there aren't many. One small study (Scott & Stradling, 1997) looked at compliance with homework instructions for two variations of exposure therapy for PTSD. Compliance was pretty low. In that study, all treatment was conducted through homework, there was no actual in-session exposure. Given that the only exposure that occurred was as homework, it is not surprising that there was a relationship between how much homework people did and how well they got: People who did very little homework derived very little benefit. Marks et al. (1998) also found that people who did more homework had better outcomes. However, in both of these studies, whether or not (or how much) homework was done was controlled by the patient, it wasn't manipulated by the researchers. So, we can't really draw causal conclusions froms these data. We don't know for sure whether homework improves outcome. For example, it could be that only people who are benefitting from the treatment are willing to conduct homework. So homework compliance could be a result of improvement, rather than improvement being the result of homeworkd. The issue has been looked at more systematically in other anxiety disorders, particularly agoraphobia and phobias. In these anxiety disorders, there is evidence that homework does in fact improve outcome.

Are people more compliant with other kinds of therapy than exposure therapy? This is another tough question. When you consider compliance with in-session tasks, you can think of treamtent dropouts and treatment refusals as possible indexes of compliance. If you survey research studies on PTSD, you find that people tend to drop out more from any kind of active treatment (exposure therapy, stress management, cognitive therapy, EMDR) compared to control conditions such as waitlist, supportive counseling, or relaxation. However, there is not much difference between active treatments. It is true that within a given study, there may be more or less dropouts from one group or another. But when you survey the literature, as colleagues of mine have done in a recent meta-analysis (Hembree et al., in press) the differences tend to wash one another out, and you find no differences between active treatments.

What about the real world? Drop out rates in the real world are much higher than they are in research. Zayfert and colleagures recently surveyed patients offered exposure therapy for PTSD through a medical school based outpatient clinic (i.e., fee-for-servicen, not as part of a study). If people provided a reason for not receiving exposure therapy (many chose not to anwer the questions), the primary reasons given for not participating in therapy had to do with variables that would affect any kind of therapy: costs too much, don't have a babysitter, clinic not on my bus route, etc. Very few people said they wouldn't enter therapy because they would have to confront the memory.

Are peopel more compliant with homework if the homework doesn't invovle exposure? The only data relevant to PTSD come from the Marks et al. study mentioned above. The overall homework compliance rate was 63% (SD = 30%), but compliance differed across treatments. Compliance rates were as high or higher than the mean for exposure therapy plus cognitive restructuring (M = 75%, SD = 29%), relaxation (M = 69%, SD = 28%), and exposure therapy alone (M = 65%, SD = 29%), while compliance was substantially below the average for cognitive restructuring alone (M = 43%, SD = 28%).

All-in-all, it looks to me that, although compliance can be a serious barrier to treatment, it is true for all kinds of therapy, and not unique to exposure therapy.

Now, what about "therapist compliance." That is, "Will therapists use exposure therapy correctly?" This is another really tough question that we are only just beginning to address in our research. Here is the good news. We are currently preparing the main outcome paper for a study in which our clinic trained and supervised master's level therapists from our city's local rape crisis clinic in the use of exposure therapy, either with or without formal cognitive restructruing. Guess what? The community therapists did every bit as well as we did!

We are continuing to do research on the process of dissmination of exposure therapy from the ivory tower down to the trenches. We are now also addressing the quesiton of how does this compare to the treatment they would have otherwise gotten (i.e., "treatment as usual"). We will have some better nswers to these questions sometime in the next 3-5 years.

The last excellent point you raised is whether treatment X administered badly is better than treatment y administered badly. This speaks to whether or not a treatment is robust. By robust, I mean that the treatment works even if you violate the optimal parameters. For example, if you absolutely need to take a pill every four hours in order for the pill to work, then it is not very robust. By contrast, a robust medication is one that would still be helpful (maybe not optimally helpful) even if you forgot to take the occassional dose. So your question boils down to "how robust are differnt forms of psychotherapy for PTSD?"

Good question, no good answer as of yet. The best I can tell you is that, on the one hand, different research groups do exposure therapy in slightly different ways, and regardless of that, they all tend to work. To be fair, it should also be acknowledged that the differences between protocals are not all that huge. We also know that, at least with other applications of exposure therapy, certain parameters are associated with better outcome, with some of the most important ones being how long the exposure lasts (longer is better, at least up to a certain point), repetition (more is better, again at least up to a certain point), level of fear activation (moderately high -- SUDs around 80-90 on a 0-100 scale -- is better than low or really high), and that in vivo tends to be better for phobias than imaginal exposure. However, none of these is critical, in that exposure works even when you violate these general paramters. So, people can benefit from two 20 minute exposures, but perhaps not quite as much as they would from a single 40-minute expousre.

So, there is at least some degree of robustness to exposure therapy. What about EMDR? I find it interesting that all of the dismantling studies fail to find substantially reduced outcome when you remove eye movements. This would suggest a certain robustness. On the other hand, when EMDR doesn't do well in a particular study, people are ready with specualtion as to critical violations in treatment integrity. If you go back to a series of posts amongst Louise Maxfield, Sandra, and myself back in about November of 1992, we discuss some of the violations of treatment integrity committed by Devilly and Spence (1999). They (Devilly and Spence) did such horrible things as asking patients to rate VoC for the negative cognition as well as the positive cognition and asked for SUDs during treatment too often. With regard to the VoC for negative cognitions, Sandra suggested that doing so could interfere with EMDR if patients didn't see much change in the VoC scores, they then may get demoralized. Interesting speculation. But couldn't the opposite be the case? If patients saw that they were improving, they may get energized and become even more committed to therapy Anyway, it seems that at least some EMDR experts seem to think that EMDR is very senstive to deviations from the protocol. If true, then EMDR would not seem to be very robust.

As usual, however, I think the best answer to the questions you raise is an empricial answer: let's actually find out what happens when you a) disseminate treatments from the tower to the field and b) violate papratermters of a treatment. Does the efficacy fall apart or does it hold up?

I guess I have one last comment. As you describe, some therapists are not "comfortable" with hearing details of trauma survivors stories. Such people probably should not be doing exposure therapy. Fortunately, stress management and cogntive therapy can also be helpful for PTSD. Such therapists could chose to learn and use one of these alternative treatments, or they could chose to refer PTSD patients to therapists who are better equipted to provide appropriate treatment. This message is even stronger for the treatment of OCD: All current evidence would indicate the only form of psychotherapy that has any meaningful effect on OCD is exposure therapy. If you don't know how to use exposure therapy, then you shouldn't offer treatment for OCD. Refer them for an appropriate psychiatric consult (SRI meds work for at least some people with OCD) and/or to a therapist trained in behavior therapy.

Replies:

Re:Exposure in the real world, by Cahill, 02/07/03 Re:Exposure in the real world, by Ulrich Lanius, Ph.D., 02/07/03

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